Access Care Hospice

“Upon patient record review, 2 of 14 records reviewed (Patient #6, #7) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient #6: The record indicated the pain score was a “4” on admission (02/26/25) and the self identified threshold was a “3”. On 02/27/25 the pain level was a “6” and the self identified threshold was a “3”. On 03/06/25 the pain score was a “7”, there was no self identified threshold documented. The patient need for pain control was not met. Patient #7: The record indicated the pain score was a “7” on admission (01/10/25) and the self identified threshold was a “3”. On 01/17/25 the pain level was a “5” with a self identified threshold was a “2”. The patient need for pain control was not met.”

“Upon patient record review, 1 of 14 records (Patient #1) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: The record indicated on 05/13/25 during IDG there was no review that included effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and or drug therapy currently associated with laboratory monitoring, this section of the review was left blank. The medication profile had multiple medications listed.”

“Upon patient record review, 2 of 14 charts reviewed (Patient #2, #5) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #2: The chart indicated the start of care was on 04/21/25, there was no evidence of an initial bereavement risk assessment having been completed at the time of the survey. Patient #5: The chart indicated the start of care was on 03/15/25, there was no evidence of an initial bereavement risk assessment having been completed at the time of survey.”

“Upon patient record review, 5 of 14 record reviewed (Patient #2, #3, #4, #5, #6) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #2: The patient was admitted on 04/21/25 as a full code, there was no individualized written plan of care that reflected patient/family goals and interventions based on the problem. COS. In addition, the patient was taking Xarelto 20mg po every evening at the start of care, there was no individualized written plan of care that reflected patient/family goals and intervention regarding bleeding precautions. COS. Patient #3: The patient was admitted on 02/07/25 and was taking Brilinta 90mg po BID, there was no individualized written plan of care that reflected patient/family goals and interventions regarding bleeding precautions. COS. Patient #4: The patient was admitted on 05/07/25 as a full code with no mortuary listed, there was no individualized written plan of care that reflected patient/family goals and interventions based on the full code status and choice of mortuary. COS. In addition, the patient is taking Humulin R 100U/ml per sliding scale and Semglee 100U/ml 18U SQ QHS, there was no individualized written plan of care that reflected the patient/family goals and interventions to include who will check the blood sugar, how often to check the blood sugar and what levels to report and who to report it to. COS. Patient #5: The patient was admitted on 03/15/25 as a full code and no mortuary listed, there was no individualized written plan of care that reflected patient/family goals and interventions based on the full code status and choice of mortuary at the time of the survey. COS. Patient #6: The patient was admitted on 02/26/25 as a full code and no mortuary listed, there was no individualized written plan of care that reflected patient/family goals and interventions based on the full code status and choice of mortuary at the time of the survey. COS.”

“Upon patient record review 2 of 14 records reviewed (Patient #8, #10) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #8: The record indicated the Chaplain made an assessment documenting the patient had concerns about the afterlife, fear, loneliness and guilt on admission on 01/08/25 and did not visit again until 04/07/25. Helping the patient with these needs were not met at the time of the survey. Patient #10: The record indicated the Chaplain made an assessment documenting the patient had concerns about unfinished business, concerns about the afterlife, loneliness, anxiety and fear on admission on 01/07/25 and did not visit again until 04/06/25. In addition, the Social Worker made an assessment documenting the decision on which mortuary to use was pending and stressed the importance of having advanced directives and final arrangements in order. The Social Worker did not make a second visit until 03/25/25 also identifying at this time there were no burial plans. Helping the patient with these needs were not being met at the time of the survey.”

“Upon patient record review 2 of 14 records reviewed (Patient #1, #6) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1: The chart indicated on 01/15/25 that the IDG ordered aide visits for 2 X W. There were no visit notes on the chart at the time of the survey. COS. Patient #6: The chart indicated on 03/07/25 that the IDG ordered aide visits for 3 X W. There were no visit notes on the chart at the time of the survey. COS.”